In the first study of its kind, researchers have asked people to describe in their own words what it’s like to live with Avoidant Personality Disorder – a diagnosis defined by psychiatrists as “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation”. Like all personality disorder diagnoses, AVPD is controversial, with some critics questioning whether it is anything other than an extreme form of social phobia.

To shed new light on the issue, lead author Kristine D. Sørensena, a psychologist, twice interviewed 15 people receiving outpatient treatment for AVPD: 9 women, 6 men, with an average age of 33, and none of them in work. Writing in the Journal of Clinical Psychology, the researchers said the overarching theme to emerge from the in-depth interviews was the participants’ struggle to be a person. “They felt safe when alone yet lost in their aloneness,” the researchers said. They “longed to connect with others yet feared to get close.” In the researchers’ opinion, the participants’ profound difficulties with their “core self” and in their dealings with others do indeed correspond to “a personality disorder diagnosis”.

Beneath the overarching theme of struggling to be a person, there emerged two main themes, the first being “fear and longing“. This included participants’ descriptions of having to put on a mask when socialising and their difficulty feeling normal. “I notice that you spend incredible amounts of energy. You just spend your entire consciousness in just not … trying not to make a fool out of yourself and appear normal.” (Steve). This constant performance meant they felt other people never really knew them. “I have never felt seen. Not even my mother knew me like that. I know I have missed it. I never felt loved.” (Lily). There were some rare exceptions to these difficulties. For instance, one participant said they felt authentic when with their young daughter, yet other participants described how, as their children grew older, their usual insecurities returned even when in their company.

Another difficulty that was mentioned repeatedly was the dread of getting close to others. “I am very, very suspicious of people. Not that they would harm me physically, but what are their intentions? Or they seem nice, but really, they are not.” (Eva). Coping measures included only interacting through email or text message, and when in physical company, avoiding eye contact.

The participants also described a conundrum – the solitude that brought them comfort and safety was also suffocating. They were “feeling sad, almost grieving when they were alone”, the researchers said. “There comes a heaviness, like ‘now you are alone again little man, and you will never manage this; you will die alone’” (Peter). To cope, the participants said they kept busy playing computer games and listening to music. Most effective in this regard were physical sports and hobbies like making music, yet sadly the relief evaporated as soon as thoughts of being evaluated crept into mind.

The second main theme was “A doubting self” – including chronic insecurity and a fleeting sense of self. Participants had the perception that other people breeze through life and have no trouble being themselves. Related to this, the participants were constantly struggling to make sense of their own persistent insecurities. “There is always something grinding in my head, so there is no rest. I do not know how to answer myself to make it better” (Anita).

The constant acting and pretense when in company led to feelings “like one is not even there” (Amanda). Sometimes this developed into an emotional hollowness. “I think that it is real fun or should be, but I do not feel anything” (Eva). After wearing a mask for so many years, some participants feared they had forgotten who they truly were underneath. “I feel like I do not know myself anymore” (Amanda). On the positive side, participants found time in nature was therapeutic, especially when immersed in a physical challenge. “There it is only me. I do not have to perform something for others to see. I find enormous pleasure from reaching the mountaintop. Then, you are kind of free” (Elsa).

In short, the researchers said that their participants spend so much time “reflecting on themselves that it seemingly disrupted their everyday life functioning”. They also lacked feelings of belonging, attachment and intimacy. Their suspicion of others and the burden of keeping up appearances “caused the participants to retreat from and thus miss social experiences that might have provided more trustworthy and comforting answers to questions related to the inner mental lives of themselves or others.”

Sørensena and her colleagues said these insights could be useful for therapists. The therapeutic alliance (a warm, trusting relationship between therapist and client) – always important – will be even more critical for clients with avoidant personality disorder. “The therapeutic relationship provides an opportunity for persons diagnosed with AVPD to experience being met with acceptance and understanding,” the researchers said.

They added that “through a reflective process, patients might begin to make sense of why they do not manage what seems easy for most people. With this realization, their motivation to encounter new social learning might increase, together with a beginning of acceptance of life’s inherent uncertainties. Research on treatment of AVPD has been scarce and inconclusive, but the suggestions above do align with promising recommendations emphasizing the importance of social skills training and drawing on findings from social cognition research on mentalization, self‐other differentiation, interpersonal grounding for building a self‐concept, and affect consciousness.”